Nail Psoriasis: Evaluating Quality-of-Life Measures and Treatment Gaps

Announcer:
You’re listening to On the Frontlines of Psoriasis on ReachMD. And now, here’s your host, Dr. Charles Turck.

Dr. Turck:
This is On the Frontlines of Psoriasis on ReachMD. I’m Dr. Charles Turck, and joining me today is Dr. Shari Lipner, who’s an Associate Professor of Clinical Dermatology and the Director of the Nail Division at Weill Cornell Medicine/New York-Presbyterian Hospital. Together, we’ll be discussing her systematic review, focusing on patient-reported quality of life outcomes for those with nail psoriasis, focusing on disease severity and treatment.

Dr. Lipner, welcome to the program.

Dr. Lipner:
It’s great to be here, Dr. Turck.

Dr. Turck:
Well, to help set the stage for us, Dr. Lipner, how common is nail involvement in psoriasis, and what makes it so impactful beyond cosmetic concerns?

Dr. Lipner:
Nail involvement in psoriasis is actually super common. So 80 percent of patients with cutaneous psoriasis have nail changes during their lifetimes. Also, five to 10 percent of all psoriasis patients have isolated nail psoriasis, meaning nail psoriasis with no or limited skin involvement, and it’s so hard to diagnose these patients because we don’t have the clues from the skin. And nail psoriasis is not just aesthetic. Pain is a common symptom, and patients often have difficulty performing daily activities, and psychosocial consequences are quite common.

Dr. Turck:
Now, with that background in mind, let’s zero in on your article. After reviewing 15 studies, what else did you learn about the impact of nail psoriasis on patients’ quality of life, especially compared to those with skin disease only?

Dr. Lipner:
So we started out with 3,853 abstracts, and out of those, we screened 430 full text, and then we analyzed 15 studies that met our criteria. And what we found was that patients with nail psoriasis had higher Psoriasis Area Severity Index—meaning they had higher severity of disease and Dermatology Life Quality Index scores—than those with psoriasis without nail involvement. We also found that women had higher PASI scores and higher DLQI scores than men.

Dr. Turck:
As a follow-up to that, how well do presently used tools, like the Dermatology Life Quality Index, capture the patient experience in nail psoriasis, and are there any gaps we should be aware of?

Dr. Lipner:
So the Dermatology Life Quality Index was designed to evaluate quality of life in patients with skin disease, not nail disease, so it’s not specific to psoriasis, and it’s not specific to nail psoriasis. In addition, the Dermatology Life Quality Index scores for nail psoriasis reported in studies were generally low and not consistent with what nail psoriasis patients report in real-life practice. So based on that, the Dermatology Life Quality Index score probably does not capture the real-life experience of nail psoriasis patients.

Dr. Turck:
For those just tuning in, you’re listening to On the Frontlines of Psoriasis on ReachMD. I’m Dr. Charles Turck, and I’m speaking with Dr. Shari Lipner about her systematic review that evaluated the impact of nail psoriasis in treatment on patients’ quality of life.

So if we continue examining your review, Dr. Lipner, which of the biologic therapies evaluated showed the greatest improvement in patient-reported outcomes, and how did that align with clinical response?

Dr. Lipner:
So for all biologic treatments—and that included infliximab, etanercept, adalimumab, ustekinumab, and secukinumab—there were statistically significant improvements in both NAPSI and quality of life with treatment. Specifically, infliximab demonstrated the greatest percentage improvement in NAPSI, but that wasn’t congruent, necessarily, with quality-of-life scores. So when comparing reported percent improvement in quality of life across treatment types, adalimumab had the greatest percent improvement from baseline.

Dr. Turck:
Now, given all these findings, were there any notable limitations in the literature that could affect how we interpret them?

Dr. Lipner:
Yes. So there are several important limitations. First, there are a lack of studies evaluating quality of life in nail psoriasis patients meeting our screening criteria. In addition, none of the studies included children, and only two studies included adults over the age of 75. And we know that the pediatric population and the population of older adults are commonly affected by nail psoriasis and definitely bothered by nail psoriasis.

Another major limitation is that topical treatments, intralesional treatments—including Kenalog and methotrexate—and systemic treatments, including small molecules, were excluded because they did not meet the inclusion criteria, so we only reported on studies with biological therapies because they met the inclusion criteria for our review. But strengths of our study are that the quality of evidence for the treatment studies was quite high, and the risk of bias was low.

Dr. Turck:
And if we look ahead before we close, Dr. Lipner, what would you like to see in future research or clinical practice when it comes to assessing quality of life in patients with nail psoriasis?

Dr. Lipner:
We learned from this study that nail disease has a significant impact on quality of life for psoriasis patients. I mean, we know that from our clinical practice, but I think we showed this in a statistically significant manner. However, very few studies looked at patient-reported outcome measures, and those that did rarely used nail psoriasis-specific quality of life scales. Therefore, future research should include nail psoriasis-specific scales, such as the Nail Psoriasis Quality of Life Measure, the Nail Assessment in Psoriasis and Psoriatic Arthritis questionnaire, and the Nail Psoriasis Quality of Life 10 questionnaire. And in clinical practice we recommend that dermatologists inquire about quality-of-life impact in patients with nail psoriasis, as it influences our treatment decisions.

Dr. Turck:
Well, as those forward-looking comments bring us to the end of today’s program, I want to thank my guest, Dr. Shari Lipner, for joining me to discuss her research on how nail psoriasis can impact patients’ quality of life.

Dr. Lipner, it was great having you on the program.

Dr. Lipner:
It was great speaking to you, Dr. Turck, and thank you for your interest in our study.

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